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Peptic ulcer disease is uncommon in children. Ulcers may be primary or secondary in nature. When primary ulcers occur, they are usually duodenal. The vast majority of primary duodenal ulcers are associated with Helicobacter pylori infection of the gastric antral mucosa. Although H. pylori is almost always acquired in childhood, peptic ulceration is rare under the age of 10 years. The host or bacterial factors which result in a minority of H. pylori infected individuals developing duodenal ulcer disease are as yet unknown. Secondary ulceration which may be gastric or duodenal can occur at any age. It may be life threatening in the acute phase due to the risk of perforation, but after healing, recovery is usually complete.

Background. Despite the fact that the main cause of duodenal ulcer incidence and recurrence is the Helicobacter pylori bacterium, more than 80% of Helicobacter pylori-infected people never develop an ulcer. Diet may be one of the most important environmental factors contributing to duodenal ulcer. Aims. To explore the role of diet in causation, treatment and prevention of duodenal ulcer recurrence. Methods. All research papers published in English from 1966 to October 1999 present in Medline, involving human subjects, and having duodenal ulcer as outcome, entered the review. Results and Conclusions. Soluble fibre from fruit and vegetables seem to be protective against duodenal ulcer and refined sugars a risk factor. The role of fibre in the treatment and prevention of recurrence of duodenal ulcer is uncertain, as is that of essential fatty acids. However, none of the epidemiological studies on the relationship between diet and duodenal ulcer disease controlled for Helicobacter pylori.

Polymerase chain reaction and cytotoxin assays were performed to identify as Helicobacter pylori type I ( cagA + /tox + ) or type II ( cagA − /tox − ) 56 (59.6%) strains from 94 patients. Of these patients 64 were affected by nonulcer dyspepsia (NUD), 10 by gastric ulcer (GU), 19 by duodenal ulcer (DU), and 1 by both GU and DU. H. pylori strains were tested for cagA using two sets of primers; target sequences were detected in 40–42/56 (71.4–75%) depending on the set of primers used, while cytotoxin-producing strains (tox+) were 26/56 (46.4%). Tox + strains were isolated in 13/32 (40.6%), 2/7 (28.6%), and 11/17 (64.7%) in NUD, GU, and DU patients, respectively. However, the different percentage between cagA + strains from NUD patients (13/32; 40.6%) and patients with ulcerative diseases (13/23; 54.2%) is not statistically significant ( p = 0.462). Because the two sets of primers employed for amplification of cagA target sequences give different results, we concluded that cagA alone could not be taken as predictive factor for severity of gastroduodenal disease. It has been found that H. pylori type I is associated with duodenal ulcer disease.

Helicobacter pylori is the major cause of antral gastritis in children, however, it is not always associated with symptoms. The exception to this occurs in duodenal ulcer disease with which H. pylori is linked in children albeit less strongly than in adults. Duodenal ulcers do not recur in older children following eradication of H. pylori. The importance of asymptomatic carriage of H. pylori in children, particularly in relation to the duration of this infection and the subsequent development of gastric cancer, remain to be established. Helicobacter pylori is associated with both hypochlorhydria and persistent diarrhoea in children in developing countries, but the significance of this association is still unknown. Although there is no consensus on the optimal regimen for treating H. pylori infection in children, dual therapy with amoxycillin and bismuth subcitrate for 2 weeks followed by monotherapy with bismuth subcitrate for a further 6 weeks will eradicate H. pylori infection in the majority of children. Those who relapse may be treated with a repeat course plus metronidazole for 4 weeks. Compliance with such regimens is a problem and shorter treatment courses that are equally effective in children need to be defined. Similarly, studies are required on the influence of the intrafamilial reservoir of H. pylori infection on relapse after treatment and the need for whole family eradication therapy.

A retrospective study of 31 consecutive bleeding duodenal ulcer (DU) patients and, as controls, 62 active DU subjects without bleeding episodes was conducted in order to ascertain whether bleeding DU patients have particular clinical or functional characteristics. The patients were followed for 15.6 and 17.4 months, respectively, after diagnosis. The following parameters were taken into account: sex, age, family history of ulcer, blood group (ABO system), ulcer pain, nonsteroidal anti-inflammatory drug (NSAID) consumption, cigarette smoking, alcohol and coffee consumption, ulcer site, fasting serum gastrin and pepsinogen group A, basal acid output (BAO), and maximal acid output (MAO). Statistics were gathered using the Student's t test and Fisher's exact test. Bleeding DU patients had less ulcer pain ( P P

The optimal treatment of duodenal ulcer disease today requires familiarity with a variety of operative approaches. Experience and judgment are needed to select the best procedure for the individual patient presenting with a specific ulcer complication. Improved medical therapy has relegated surgery largely to the role of emergency life-saving intervention. Nonetheless, the goal of surgery remains cure of the ulcer diathesis with avoidance of postoperative side effects. Toward this end, proximal gastric vagotomy has proved itself to be the operation of choice, not only for intractable pain, but also for perforation and perhaps for bleeding in selected good-risk patients. Its efficacy in the treatment of obstructing duodenal ulcer has not been demonstrated. Modifications of proximal gastric vagotomy, including the use of laparoscopic techniques, are currently being evaluated in patients with intractable duodenal ulcer pain.

Antral biopsy specimens were processed for Helicobacter pylori by Gram staining, rapid urease test (RUT) and culture from 25 patients with symptoms of duodenal ulcer, amongst whom the positivity rate was 84%. Follow up of 16 patients after appropriate therapy showed complete regression of the disease in 87.5% of cases whereas in 12.5% of cases a decrease in the extent of duodenal ulceration was noted.

The gastrin response to a liquid meal with and without secretin infusion was studied in nine patients undergoing selective or truncal vagotomy with pyloroplasty for duodenal ulcer disease. Fasting gastrin levels were significantly increased in eight of nine patients after vagotomy, but secretin infusion did not consistently suppress these basal gastrin levels either pre- or postoperatively. Infusion of secretin did significantly lower the integrated gastrin response to feeding both pre- and postoperatively in eight of nine patients. Vagotomy alone did not significantly alter the integrated gastrin response to feeding. This data gives evidence that secretin infusion remains a helpful diagnostic test, differentiating those patients with recurrent ulcer and elevated gastrin levels postvagotomy from those patients with occult Zollinger-Ellison syndrome.

A biopsy-proved case of acute interstitial nephritis related to the use of cimetidine in duodenal ulcer disease is presented. The biopsy findings support a strong clinical impression of a hypersensitivity nephritis.

There are conflicting reports on the influence of cigarette smoking on healing in patients with duodenal ulcer; some studies show an adverse effect on healing rate and others no effect. This study reports the influence of smoking on short-term healing and relapse rate in 135 patients with duodenal ulcer who were treated with cimetidine (90), ranitidine (25), and oxmetidine (20), all powerful H2-receptor antagonists. Ulcer healing and relapse were documented endoscopically and all studies were performed in a double-blind manner. In the short term, 95% of nonsmokers healed compared with 63% smokers (p less than 0.01) and there was a positive correlation between failure to heal and number of cigarettes smoked. During a 12-mo follow-up examination after healing and on no treatment, 53% of nonsmokers and 84% of smokers relapsed (p less than 0.01). These results show that smoking adversely affects healing of duodenal ulcer with H2-receptor antagonists and that continued smoking leads to a higher relapse rate.

Five adults with midgut nonrotation were treated at Tripler Army Medical Center between January 1, 1966 and January 1, 1974. These patients usually presented with vague epigastric or lower abdominal symptoms. Initial diagnosis was generally based on barium enema studies revealing an entirely left-sided colon. However, on upper gastrointestinal series the absence of a normal duodenal “c” loop with straightening is also seen. Duodenal obstructive bands are rarely documented radiographically. Surgical intervention is frequently delayed in these patients due to the “atypical” symptoms and lack of correlation of these symptoms with objective radiographic changes. The high incidence of associated duodenal ulcer disease, the frequent occurrence of bowel obstruction, the persistence of chronic abdominal pain in the untreated patient, and the resolution of symptoms after anatomic correction point to the need for an aggressive approach to treatment in those patients who have chronic recurrent symptoms secondary to midgut nonrotation.

There are a large number of patients with chronic duodenal ulcer disease who warrant long-term maintenance therapy to diminish the risk of recurrence and there by the risk of further complications such as gastrointestinal bleeding. The efficacy of sucralfate has been compared with both placebo and histamine (H 2 )-receptor antagonists and sucralfate in a dose of 1 g twice a day or 2 g taken at night. It is a safe and effective medication in preventing duodenal ulcer recurrence. However, duodenal ulcer relapse rates always exceed 20 percent and frequently approach 50 percent, whether the therapy be H 2 -receptor antagonists or sucralfate, and the use of dosages that are half the healing dose seems irrational. It would therefore seem reasonable to continue maintenance therapy at the healing dose, whatever medication is used. Any increased costs for drugs should be outweighed by savings in indirect costs.

Recent developments in medical management which appear of major importance include the development of antagonists of H 2 -receptors of histamine, the prostaglandins, and transendoscopic instrumentation. Until we have more long-term and complete evaluation of ulcer treatment, we will continue to base therapy on anecdotes and incomplete data.

The effect of cimetidine in duodenal ulcer disease was assessed in a double blind, controlled, prospective, multicenter clinical trial in both inpatients and outpatients. Endoscopic evidence of ulcer healing and symptom evaluation were monitored in 308 patients who received either 1.2 g of cimetidine per day or placebo for periods varying from 2 to 6 weeks. Both groups of patients received antacids only for symptom relief. At the end of 2 weeks of inpatient therapy, 56% of the cimetidine-treated patients and 37% of the patients treated with placebo ( P P

73 patients with recently healed duodenal ulcer were randomly allocated to a diet high or low in fibre for a period of 6 months. During this period, ulcer recurrence was found in 28 (80%) of the 35 patients in the group on a low fibre diet compared with 17 (45%) of the 38 patients in the group on a high fibre diet (p

Mean fasting preoperative pancreatic polypeptide levels in a group of 18 patients with duodenal ulcer disease were 462 ± 88 pg/ml, with 13 patients having markedly elevated levels (mean 600 ± 106 pg/ml) and 5 patients having normal or minimally elevated levels (mean 112 ± 32 pg/ml). Mean fasting postoperative pancreatic polypeptide levels significantly decreased to 136 ± 36 pg/ml, with decreases occurring in 12 of 13 patients who had had markedly elevated preoperative values. Parietal cell vagotomy and truncal vagotomy produced significant reductions in both fasting pancreatic polypeptide levels and in the glucose-stimulated pancreatic polypeptide response during the first 60 minutes. There was no correlation between pancreatic polypeptide levels (fasting and stimulated) and duration of ulcer disease, indications for ulcer operation, type of operation, or age of patient. These results suggest that elevated fasting pancreatic polypeptide levels may indicate vagal hyperactivity in some patients with duodenal ulcer.

During the twenty year span from 1951 to 1970, the combined operation was selected as the procedure of choice 663 times in the surgical management of duodenal ulcer disease. A retrospective study of these cases represents a 70 per cent follow-up rate; thirty-two additional patients expired during this period of causes unrelated to peptic ulcer disease or the procedure, bringing the crude follow-up rate to 77 per cent. The known recurrence rate was 0.85 per cent and the mortality 0.6 per cent. None of the deaths were due to the operative procedure itself. Diarrhea (11 per cent) and dumping (24 per cent) were the principle postoperative sequelae, neither of which represented a significant problem after twelve to fourteen months. Their incidence after 1960 in this series was decreased due to improved technic, better overall total surgical care, and reduction of the extent of resection from 75 to 50 per cent. The results, as interpreted by surgeon, patients, and gastroenterologist, have been reviewed.

Choledochoduodenal fistula in the absence of primary biliary disease is an unusual complication of duodenal ulcer disease. A case seen recently at the Johns Hopkins Hospital is reported and the literature on Choledochoduodenal fistula secondary to penetrating duodenal ulcer is reviewed. Treatment should be individualized according to the clinical situation. The elderly or poor risk patient, in the absence of complications, can be treated with an intensive medical regimen of antacids or cimetidine, or both. Surgical therapy is indicated in patients with a history of intractability or complications of duodenal ulcer disease. Exclusion-type gastrectomy is optimal. An attempt at division of the fistula itself is hazardous and unnecessary since long-term complications are rare.

Psychological factors may play an important role in peptic ulcer disease, but this has not yet been proven. The psychosomatic theory suggests than an unconscious conflict, by some yet unknown route, results in an increase in acid-pepsin secretion or a decrease in resistance of the duodenal mucosa, thereby upsetting the normal balance between injurious and defensive factors. At least some ulcer patients have a conflict over an exaggerated need for dependency and a desire to be a self-sufficient adult. In a prospective study [13]aimed at predicting individuals predisposed to ulcer disease, the presence of this dependent-independent conflict was confirmed. Since this personality profile was found to be associated with hyperpepsinogenemia which has since been shown to be genetically determined, the intriguing possibility exists that the psychological traits are also genetically determined. This personality profile may be associated with a predisposition to ulcer disease, but so far there is no clearcut evidence showing that the psychological factor actually influences the gastrointestinal disorder: Clinical experience suggests that “stress” is frequently a contributory factor to exacerbations of the ulcer disease. We are coming to recognize that a number of different pathophysiological mechanisms may lead to a duodenal ulcer. It seems likely that psychological factors may be found to be important in some forms of the disease and not in others. Consideration of psychiatric treatment should be based on the individual's psychological characteristics and not solely on the presence of ulcer disease.

Data were combined for statistical analysis from four European trials comparing enprostil (35 μ g twice daily) with cimetidine (400 mg twice daily) in the treatment of duodenal ulcer, using a double-blind, randomized design with endoscopic control. A total of 369 patients entered the trials, of whom 348 were eligible for the efficacy analyses and 362 for the safety analyses. Patients were allowed antacids as needed. The pooled cumulative healing rates at two, four, and six weeks were 40, 75, and 84 percent, respectively, for enprostil and 42, 77, and 87 percent, respectively, for cimetidine. There were no significant differences between treatments. Healing rates in both groups were reduced in smokers, in those with larger ulcers at baseline, and in those who reported a higher consumption of alcohol. Age, however, had no effect on healing rates. Digestive system complaints were reported more frequently in the enprostil group, whereas central nervous system complaints were more than twice as frequent in the cimetidine group.

1. 1. Failure of the stomach to drain after the Finney pyloroplasty and truncal vagotomy resulting in two deaths is difficult to explain. 2. 2. Gastric atony after truncal vagotomy is most marked in patients with pre-existing pyloric obstruction and gastric decompensation. This factor, combined with a mechanical block at the anastomosis, may offer an explanation for the failure of drainage and complete gastric retention. 3. 3. It has been assumed that removing the spur or tongue of tissue at the gastroduodenal anastomosis when performing Finney pyloroplasty and truncal vagotomy promotes better drainage and aids in preventing the hazards of gastric atony. 4. 4. It appears that the excellent results obtained in the use of the modified Finney pyloroplasty associated with obstructed duodenal ulcer, with or without massive bleeding, have merit and support the conclusions that have been made.

Fourteen patients undergoing vagotomy and pyloroplasty for duodenal ulcer disease were studied with oral glucose tolerance tests before and 4 to 8 weeks after surgery. Although none had a history of diabetes or glycosuria, 6 were chemically diabetic preoperatively. Results showed that glucose levels were higher postoperatively than preoperatively at 30 and 60 min after glucose ingestion. Glucose levels at 120 min, however, were significantly lower than those preoperatively: Five diabetics with elevated 2-hr glucose values preoperatively had normal 2-hr values postoperatively. The data suggested that the 2-hr value in the oral glucose tolerance test after vagotomy and pyloroplasty will underdiagnose the diabetic state.

Rates of gastric hydrochloric acid secretion were compared in 10 children with active duodenal ulcer (DU) and 14 non-duodenal ulcer children. Duodenal ulcer was diagnosed by gastroduodenoscopy or by evidence of an ulcer crater on upper gastrointestinal radiographs. Duodenal ulcer disease was excluded in the comparison group by similar criteria. Basal acid output in DU children tended to be higher, but the difference was not statistically significant (P > 0.05). Maximal acid output was significantly higher in DU children than in the comparison group whether expressed as milliequivalents per hour (P

Various polysaccharides have been evaluated in the management of peptic ulcer disease; however, inherent side effects common to most polysaccharide sulfates have contraindicated their acceptance. The sulfate ester of the saccharides, aluminum salt of sucrose sulfite, has proven devoid of significant side effects and is advocated for clinical trial in peptic ulcer disease. Reports from Japanese investigators have indicated efficacy in doubleblind, randomized studies, both in gastric and duodenal ulcer disease. The mechanism of action, supported by in vitro studies and animal experimentation,.indicates the aeent to be a ootent oeosin inhibitor with an affinitv fir protein, resulting in protein binding at the ulcer base to create a protective medium to promote healing. The results of a randomized, double-blind placebo controlled multicenter study in the United States in the management of duodenal ulcer disease has established the safety (absence of side effects) of this product. Symptomatic response and healing rate have been impressive at two and four-week intervals. Gastric ulcer studies have not yet permitted a conclusive opinion. Our protocol demanded evaluation of symptomatic response with endoscopic confirmation, the endoscopic findings being monitored by a panel independent of the investigators. The rigidity and accomplishments of the protocol will be discussed.